ED-dispensed mifepristone plus misoprostol improves access to early pregnancy loss care

Administering mifepristone and misoprostol in the emergency departments (EDs) appears to be effective, increasing the availability of early pregnancy loss medical management services to women during the COVID-19 pandemic in the US, as shown in a study presented at the 2022 American College of Obstetricians and Gynecologists (ACOG) Annual Clinical & Scientific Meeting.

The practice led to pregnancy resolution in 23 out of 33 women, corresponding to an effective treatment rate of 70 percent, according to Drs Roselle Bleck and Elizabeth Gurney of Montefiore Medical Center in Bronx, New York, US.

Among the 10 women (30 percent) who required additional management, four received one additional dose of misoprostol, four underwent uterine aspiration, one was given methotrexate, and another one had uterine artery embolization. Three of these interventions (30 percent) were emergent, and there were two women who also required transfusion. [ACOG 2022, abstract A08]

The demographic characteristics of the women influenced neither effective treatment nor safety outcomes with misoprostol plus mifepristone administration in the ED. A total of 28 women (84 percent) participated in the follow-up, 17 via telemedicine and 11 in person.

“Compared to misoprostol alone, medical management of early pregnancy loss with mifepristone and misoprostol has a 25-percent higher success rate, reduces subsequent uterine aspiration, and is cost-effective,” Bleck and Gurney stated.

The present data indicate that the practice of providing mifepristone and misoprostol in the ED during the pandemic can broaden access to essential services, as well as minimize repeated healthcare visits, they added.

“Further research is needed to determine whether this population [of women given mifepristone and misoprostol in the ED for early pregnancy loss] is truly at increased risk for serious complications,” Bleck and Gurney said.

Mifepristone-as-an-abortion-pill stigma

Despite the reported superior efficacy of using mifepristone as an add-on to misoprostol for early pregnancy loss treatment when compared with misoprostol alone, uptake of mifepristone remains suboptimal owing to the drug’s association with abortion, according to another study presented at ACOG 2022.

“Mifepristone access is restricted by the US Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy program, and its use [is] further limited by logistical and interpersonal barriers due to its association with abortion, especially in states with restrictive policies,” said researchers from Harvard Medical School in Boston, Massachusetts, US, led by Mugdha Mokashi, MPH.

Nearly all of the 19 obstetrician-gynaecologists in Alabama who managed early pregnancy loss and were interviewed for the study pointed to abortion-related stigma as a barrier to mifepristone use, Mokashi said. [ACOG 2022, abstract A31]

The stigmatization of mifepristone due to its association with abortion was often attributed to a lack of knowledge about the clinical use of drug for early pregnancy loss, as well as to objections by religious and political groups.

“Although providers believed mifepristone use for abortion would not be accepted in their practice, most felt that mifepristone could be successfully used for early pregnancy loss after practice-wide education on its use,” according to Mokashi.

Mokashi and colleagues called for interventions to increase clinical knowledge of mifepristone use and decrease stigma in order to optimize early pregnancy loss care.